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Julian WT, Elshami M, Ammori JB, Hardacre JM, Ocuin LM. Comparison of Hospital Volume and Risk-Standardized Mortality Rate as a Proxy for Hospital Quality in Complex Oncologic Hepatopancreatobiliary Surgery. Ann Surg Oncol 2024; 31:4922-4930. [PMID: 38700800 PMCID: PMC11236847 DOI: 10.1245/s10434-024-15361-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/09/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Centralization of hepatopancreatobiliary procedures to more experienced centers has been recommended but remains controversial. Hospital volume and risk-stratified mortality rates (RSMR) are metrics for interhospital comparison. We compared facility operative volume with facility RSMR as a proxy for hospital quality. PATIENTS AND METHODS Patients who underwent surgery for liver (LC), biliary tract (BTC), and pancreatic (PDAC) cancer were identified in the National Cancer Database (2004-2018). Hierarchical logistic regression was used to create facility-specific models for RSMR. Volume (high versus low) was determined by quintile. Performance (high versus low) was determined by RSMR tercile. Primary outcomes included median facility RSMR and RSMR distributions. Volume- and RSMR-based redistribution was simulated and compared for reductions in 90-day mortality. RESULTS A total of 106,217 patients treated at 1282 facilities were included; 17,695 had LC, 23,075 had BTC, and 65,447 had PDAC. High-volume centers (HVC) had lower RSMR compared with medium-volume centers and low-volume centers for LC, BTC, and PDAC (all p < 0.001). High-performance centers (HPC) had lower RSMR compared with medium-performance centers and low-performance centers for LC, BTC, and PDAC (all p < 0.001). Volume-based redistribution required 16.0 patients for LC, 11.2 for BTC, and 14.9 for PDAC reassigned to 15, 22, and 20 centers, respectively, per life saved within each US census region. RSMR-based redistribution required 4.7 patients for LC, 4.2 for BTC, and 4.9 for PDAC reassigned to 316, 403, and 418 centers, respectively, per life saved within each US census region. CONCLUSIONS HVC and HPC have the lowest overall and risk-standardized 90-day mortality after oncologic hepatopancreatobiliary procedures, but RSMR may outperform volume as a measure of hospital quality.
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Affiliation(s)
- William T Julian
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Vashistha N, Singhal S, Budhiraja S, Singhal D. Evaluation of ACS-NSQIP and CR-POSSUM risk calculators for the prediction of mortality after colorectal surgery: A retrospective cohort study. J Minim Access Surg 2024; 20:142-147. [PMID: 36124474 PMCID: PMC11095800 DOI: 10.4103/jmas.jmas_187_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/27/2022] [Accepted: 08/03/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Several risk calculating tools have been introduced into clinical practice to provide patients and clinicians with objective, individualised estimates of procedure-related unfavourable outcomes. The currently available risk calculators (RCs) have been developed by well-endowed health systems in Europe and the USA. Applicability of these RCs in low-middle income country (LMIC) settings with wide disparities in patient population, surgical practice and healthcare infrastructure has not been adequately examined. PATIENTS AND METHODS Through this single tertiary care, LMIC-centre, retrospective cohort study, we investigated the accuracy of the two most widely validated RCs - American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) RC and ColoRectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) - for the prediction of mortality in patients undergoing elective and emergency colorectal surgery (CRS) from March 2013 to March 2020. Online RCs were used to predict mortality and other outcomes. Accuracy was assessed by Brier score and C statistic. RESULTS Of 105 patients, 69 (65.71%) underwent elective and 36 (34.28%) underwent emergency CRS. The 30-day overall mortality was 12 - elective 1 (1.4%) and emergency 11 (30.5%). ACS-NSQIP RC performed better for the prediction of overall ( C statistic 0.939, Brier score 0.065) and emergency ( C statistic 0.840, Brier score 0.152) mortality. However, for elective CRS mortality, Brier scores were similar for both models (0.014), whereas C statistic (0.934 vs. 0.890) value was better for ACS-NSQIP. CONCLUSIONS Both ACS-NSQIP and CR-POSSUM were accurate for the prediction of CRS mortality. However, compared to CR-POSSUM, ACS-NSQIP performed better. The overall performance of both models is indicative of their wider applicability in LMIC centres also.
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Affiliation(s)
- Nitin Vashistha
- Department of Surgical Gastroenterology, Max Super Specialty Hospital, New Delhi, India
| | - Siddharth Singhal
- Department of Surgical Gastroenterology, Max Super Specialty Hospital, New Delhi, India
| | - Sandeep Budhiraja
- Clinical Directorate, Max Super Specialty Hospital, New Delhi, India
| | - Dinesh Singhal
- Department of Surgical Gastroenterology, Max Super Specialty Hospital, New Delhi, India
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Finn CB, Wirtalla C, Roberts SE, Collier K, Mehta SJ, Guerra CE, Airoldi E, Zhang X, Keele L, Aarons CB, Jensen ST, Kelz RR. Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals. JAMA Netw Open 2023; 6:e2255999. [PMID: 36790809 PMCID: PMC9932827 DOI: 10.1001/jamanetworkopen.2022.55999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities. OBJECTIVE To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022. EXPOSURES Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity. MAIN OUTCOMES AND MEASURES The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals. RESULTS A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare. CONCLUSIONS AND RELEVANCE In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.
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Affiliation(s)
- Caitlin B. Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Chris Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Karole Collier
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Shivan J. Mehta
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Pennsylvania, Philadelphia
| | - Carmen E. Guerra
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Pennsylvania, Philadelphia
| | - Edoardo Airoldi
- Department of Statistical Science, Fox School of Business, Temple University, Philadelphia, Pennsylvania
| | - Xu Zhang
- Department of Statistical Science, Fox School of Business, Temple University, Philadelphia, Pennsylvania
| | - Luke Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Cary B. Aarons
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Shane T. Jensen
- Department of Statistics and Data Science, The Wharton School at the University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
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4
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Sziklavari Z, Grabenbauer GG. [Risk-adjusted mortality rates outperform volume as a quality proxy in surgical oncology: a new perspective on hospital centralization using national population-based data]. Strahlenther Onkol 2022; 198:959-961. [PMID: 35778506 PMCID: PMC9515018 DOI: 10.1007/s00066-022-01969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Zsolt Sziklavari
- Klinik für Thoraxchirurgie, Onkologisches Zentrum Klinikum Coburg, Coburg, Deutschland
| | - G G Grabenbauer
- Radioonkologie und Strahlentherapie, Onkologisches Zentrum Klinikum Coburg, Coburg, Deutschland. .,Universitätsklinikum Erlangen, Erlangen, Deutschland.
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5
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Haak F, Soysal S, Deutschmann E, Moffa G, Bucher HC, Kaech M, Kettelhack C, Kollmar O, von Strauss Und Torney M. Incidence of Liver Resection Following the Introduction of Caseload Requirements for Liver Surgery in Switzerland. World J Surg 2022; 46:1457-1464. [PMID: 35294612 PMCID: PMC9054883 DOI: 10.1007/s00268-022-06509-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/26/2022]
Abstract
Background Centralization of care is an established concept in complex visceral surgery. Switzerland introduced case load requirements (CR) in 2013 in five areas of cancer surgery. The current study investigates the effects of CR on indication and mortality in liver surgery. Methods This is a retrospective analysis of a complete national in-hospital data set including all admissions between January 1, 2005, and December 31, 2015. Primary outcome variables were the incidence proportion and the 60-day in-hospital mortality of liver resections. Incidence proportion was calculated as the overall yearly number of liver resections performed in relation to the population living in Switzerland before and after the introduction of CR. Results Our analysis shows an increase number of liver resections compared to the period before introduction of CR from 2005–2012 (4.67 resections/100,000) to 2013–2015 (5.32 resections/100,000) after CR introduction. Age-adjusted incidence proportion increased by 14% (OR 1.14 95 CI [1.07–1.22]). National in-hospital mortality remained stable before and after CR (4.1 vs 3.7%), but increased in high-volume institutions (3.6 vs 5.6%). The number of hospitals performing liver resections decreased after the introduction of CR from 86 to 43. Half of the resections were performed in institutions reaching the stipulated numbers (53% before vs 49% after introduction of CR). After implementation of CR, patients undergoing liver surgery had more comorbidities (88 vs 92%). Conclusion The introduction of CR for liver surgery in Switzerland in 2013 was accompanied by an increase in operative volume with limited effects on centralization of care.
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Affiliation(s)
- Fabian Haak
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Savas Soysal
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Elisabeth Deutschmann
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Giusi Moffa
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Max Kaech
- Department of Surgery, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Christoph Kettelhack
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Otto Kollmar
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Marco von Strauss Und Torney
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
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Baum P, Lenzi J, Diers J, Rust C, Eichhorn ME, Taber S, Germer CT, Winter H, Wiegering A. Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data. J Clin Oncol 2022; 40:1041-1050. [PMID: 35015575 DOI: 10.1200/jco.21.01488] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
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Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph Rust
- Department of Econometrics, University of Regensburg, Regensburg, Germany.,Department of Finance, Accounting and Statistics, Vienna University of Economics and Business, Vienna, Austria
| | - Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Samantha Taber
- Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany.,Theodor Boveri Institute, Biocenter, University of Wuerzburg, Am Hubland, Würzburg, Germany
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Raoof M, Jacobson G, Fong Y. Medicare Advantage Networks and Access to High-volume Cancer Surgery Hospitals. Ann Surg 2021; 274:e315-e319. [PMID: 34506325 DOI: 10.1097/sla.0000000000005098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine how Medicare Advantage (MA) health plan networks impact access to high-volume hospitals for cancer surgery. BACKGROUND Cancer surgery at high-volume hospitals is associated with better short- and long-term outcomes. In the United States, health insurance is a major detriment to seeking care at high-volume hospitals. A third of older (>65 years) Americans are enrolled in privatized MA health plans. The impact of MA plan networks on access to high-volume surgery hospitals is unknown. METHODS We analyzed in-network hospitals for MA plans offered in Los Angeles county during open enrollment of 2015. For the purposes of this analysis, MA network data from provider directories were linked to hospital volume data from California Office of Statewide Health Planning and Development. Volume thresholds were based on published literature. RESULTS A total of 34 MA plans enrolled 554,754 beneficiaries in Los Angeles county during 2014 open enrollment for coverage starting in 2015 (MA penetration ∼43%). The proportion of MA plans that included high-volume cancer surgery hospital varied by the type of cancer surgery. While most plans (>71%) included at least one high-volume hospital for colon, rectum, lung, and stomach; 59% to 82% of MA plans did not include any high-volume hospitals for liver, esophagus, or pancreatic surgery. A significant proportion of beneficiaries in MA plans did not have access to high-volume hospitals for esophagus (93%), stomach (44%), liver (39%), or pancreas (70%) surgery. In contrast, nearly all MA beneficiaries had access to at least one high-volume hospital for lung (93%), colon (100%), or rectal (100%) surgery. Overall, Centers for Medicare & Medicaid Services plan rating or plan popularity were not correlated with access to high-volume hospital (P > 0.05). CONCLUSIONS The study identifies lack of high-volume hospital coverage in MA health plans as a major detriment in regionalization of cancer surgery impacting at least a third of older Americans.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
| | - Gretchen Jacobson
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
- The Commonwealth Fund, New York, NY
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Motomura D, Chung W, Bechara R. Endoscopic therapy for T1b esophageal cancer. Gastrointest Endosc 2021; 93:282-283. [PMID: 33353634 DOI: 10.1016/j.gie.2020.07.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas Motomura
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Wiley Chung
- Division of Thoracic Surgery, Queen's University, Kingston, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
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Pathak R, Canavan ME, Walters S, Salazar MC, Boffa DJ. Chemoradiation as a nonsurgical treatment option for early-stage esophageal cancers: a retrospective cohort study. J Thorac Dis 2021; 13:140-148. [PMID: 33569194 PMCID: PMC7867841 DOI: 10.21037/jtd-20-1187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Complete tumor removal via esophagectomy or endoscopic excision has been associated with the greatest survival in early-stage esophageal cancer. However, patient health, anatomy, or goals of care may render patients ineligible for excision or resection. In this setting, chemoradiation (CRT) may be considered as a nonsurgical approach, however the outcomes associated with CRT in early-stage esophageal cancer are incompletely understood. Methods The National Cancer Database was queried for treatment-naïve cT1/T2, N0, M0 esophageal cancer patients managed with concurrent multi-agent CRT (≥50 Gy) between 2004 and 2015. Medically inoperable patients were excluded. Kaplan-Meier curves were generated to estimate 5-year overall survival (OS) from diagnosis in both stages. Results Of the 828 patients identified, 279 were cT1 and 549 were cT2. For cases after 2010, cT1 (N=124) was further stratified in cT1a (N=32, 25.8%) and cT1b (N=46, 37.1%). Kaplan-Meier estimates demonstrated a 5-year survival of 21.7% for cT1 and 25.9% for cT2. Sensitivity analyses were performed to mitigate competing survival risk from poor health. Among 589 comorbidity-free patients (i.e., Charlson = score zero), the 5-year survival with CRT was 23.4% for cT1 and 27.8% for cT2. Finally, a subset of patients who refused a recommended surgery were evaluated with 5-year survival cT1 =33.5% and cT2 =33.4%). Conclusions Up to a third of selected patients with early-stage esophageal cancer may be cured after CRT as definitive non-surgical treatment. However, cure rates may be underestimated in this setting, secondary to persistent health-related bias.
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Affiliation(s)
- Ranjan Pathak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, CT, USA
| | - Samantha Walters
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Michelle C Salazar
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, CT, USA.,Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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11
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Chilakamarry S, Boffa DJ. Commentary: Go big or stay home? J Thorac Cardiovasc Surg 2020; 161:1711-1712. [PMID: 33514472 DOI: 10.1016/j.jtcvs.2020.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Sitaram Chilakamarry
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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12
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Azizi Machekposhti S, Movahed S, Narayan RJ. Physicochemical parameters that underlie inkjet printing for medical applications. BIOPHYSICS REVIEWS 2020; 1:011301. [PMID: 38505627 PMCID: PMC10903396 DOI: 10.1063/5.0011924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/14/2020] [Indexed: 03/21/2024]
Abstract
One of the most common types of 3D printing technologies is inkjet printing due to its numerous advantages, including low cost, programmability, high resolution, throughput, and speed. Inkjet printers are also capable of fabricating artificial tissues with physiological characteristics similar to those of living tissues. These artificial tissues are used for disease modeling, drug discovery, drug screening, and replacements for diseased or damaged tissues. This paper reviews recent advancements in one of the most common 3D printing technologies, inkjet dispensing. We briefly consider common printing techniques, including fused deposition modeling (FDM), stereolithography (STL), and inkjet printing. We briefly discuss various steps in inkjet printing, including droplet generation, droplet ejection, interaction of droplets on substrates, drying, and solidification. We also discuss various parameters that affect the printing process, including ink properties (e.g., viscosity and surface tension), physical parameters (e.g., internal diameter of printheads), and actuation mechanisms (e.g., piezoelectric actuation and thermal actuation). Through better understanding of common 3D printing technologies and the parameters that influence the printing processes, new types of artificial tissues, disease models, and structures for drug discovery and drug screening may be prepared. This review considers future directions in inkjet printing research that are focused on enhancing the resolution, printability, and uniformity of printed structures.
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Affiliation(s)
| | - Saeid Movahed
- Department of Biomedical Engineering, University of North Carolina/North Carolina State University, Room 4130, 1845 Entrepreneur Drive, Raleigh, North Carolina 27695–7115, USA
| | - Roger J. Narayan
- Department of Biomedical Engineering, University of North Carolina/North Carolina State University, Room 4130, 1845 Entrepreneur Drive, Raleigh, North Carolina 27695–7115, USA
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Papageorge MV, Resio BJ, Monsalve AF, Canavan M, Pathak R, Mase VJ, Dhanasopon AP, Hoag JR, Blasberg JD, Boffa DJ. Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery. JNCI Cancer Spectr 2020; 4:pkaa059. [PMID: 33134834 PMCID: PMC7583163 DOI: 10.1093/jncics/pkaa059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/30/2020] [Accepted: 06/26/2020] [Indexed: 11/16/2022] Open
Abstract
Background The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated. Methods Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method). Results There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life). Conclusions Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.
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Affiliation(s)
- Marianna V Papageorge
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andres F Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Maureen Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Ranjan Pathak
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Vincent J Mase
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andrew P Dhanasopon
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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14
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Boffa DJ, Mallin K, Herrin J, Resio B, Salazar MC, Palis B, Facktor M, McCabe R, Nelson H, Shulman LN. Survival After Cancer Treatment at Top-Ranked US Cancer Hospitals vs Affiliates of Top-Ranked Cancer Hospitals. JAMA Netw Open 2020; 3:e203942. [PMID: 32453382 PMCID: PMC7251445 DOI: 10.1001/jamanetworkopen.2020.3942] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hospital networks formed around top-ranked cancer hospitals represent an opportunity to optimize complex cancer care in the community. OBJECTIVE To compare the short- and long-term survival after complex cancer treatment at top-ranked cancer hospitals and the affiliates of top-ranked hospitals. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the unabridged version of the National Cancer Database. Included patients were individuals 18 years or older who underwent surgical treatment for esophageal, gastric, lung, pancreatic, colorectal, or bladder cancer diagnosed between January 1, 2012, and December 31, 2016. Patient outcomes after complex surgical procedures for cancer at top-ranked cancer hospitals (as ranked in top 50 by US News and World Report) were compared with outcomes at affiliates of top-ranked cancer hospitals (affiliation listed in American Hospitals Association survey and confirmed by search of internet presence). Data were analyzed from July through December 2019. EXPOSURES Undergoing complex cancer treatment at a top-ranked cancer hospital or an affiliated hospital. MAIN OUTCOMES AND MEASURES The association of affiliate status with short-term survival (ie, 90-day mortality) was compared using logistic regression, and the association of affiliate status with long-term survival was compared using time-to-event models, adjusting for patient demographic, payer, clinical, and treatment factors. RESULTS Among 119 834 patients who underwent surgical treatment for cancer, 79 981 patients (66.7%) were treated at top-ranked cancer hospitals (median [interquartile range] age, 66 [58-74] years; 40 910 [54.9%] men) and 39 853 patients (33.3%) were treated at affiliate hospitals (median [interquartile range] age, 69 [60-77] years; 19 004 [50.0%] men). In a pooled analysis of all cancer types, adjusted perioperative mortality within 90 days of surgical treatment was higher at affiliate hospitals compared with top-ranked hospitals (odds ratio, 1.67 [95% CI, 1.49-1.89]; P < .001). Adjusted long-term survival following cancer treatment at affiliate hospitals was only 77% that of top-ranked hospitals (time ratio, 0.77 [95% CI, 0.72-0.83]; P < .001). The survival advantage was not fully explained by differences in annual surgical volume, with both long- and short-term survival remaining superior at top-ranked hospitals even after models were adjusted for volume. CONCLUSIONS AND RELEVANCE These findings suggest that short- and long-term survival after complex cancer treatment were superior at top-ranked hospitals compared with affiliates of top-ranked hospitals. Further study of cancer care within top-ranked cancer networks could reveal collaborative opportunities to improve survival across a broad contingent of the US population.
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Affiliation(s)
- Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Katherine Mallin
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Jeph Herrin
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michelle C. Salazar
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Bryan Palis
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Matthew Facktor
- Department of Thoracic Surgery, Geisinger Heart Institute, Danville, Pennsylvania
| | - Ryan McCabe
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, Illinois
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15
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Lipitz-Snyderman A, Lavery JA, Bach PB, Li DG, Yang A, Strong VE, Russo A, Panageas KS. Assessment of variation in 30-day mortality following cancer surgeries among older adults across US hospitals. Cancer Med 2020; 9:1648-1660. [PMID: 31918457 PMCID: PMC7050094 DOI: 10.1002/cam4.2800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/05/2019] [Indexed: 11/22/2022] Open
Abstract
Background While public reporting of surgical outcomes for noncancer conditions is common, cancer surgeries have generally been excluded. This is true despite numerous studies showing outcomes to differ between hospitals based on their characteristics. Our objective was to assess whether three prerequisites for quality assessment and reporting are present for 30‐day mortality after cancer surgery: low burden for timely reporting, hospital variation, and potential for public health gains. Study Design We used Fee‐for‐Service (FFS) Medicare claims to examine the extent of variation in 30‐day cancer surgical mortality between 3860 US hospitals. We included 340 489 surgeries for 12 cancer types for FFS Medicare beneficiaries aged ≥66 years, 2011‐2013. Hierarchical mixed‐effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital‐specific risk‐standardized mortality rates (RSMRs) and 99% confidence intervals (CI). We calculated a hospital odds ratio to describe the difference in mortality risk for a hospital above vs below average quality and estimated the potential mortality reduction. Results The median number of cancer surgeries per hospital was 34. The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). In aggregate and for most cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics. For individual cancers, relative differences exceeded 20% in mortality risk between patients undergoing surgery at a hospital below vs above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements. Conclusion Quality measurement and reporting of 30‐day mortality for cancer surgery is worthy of consideration.
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Affiliation(s)
- Allison Lipitz-Snyderman
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica A Lavery
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter B Bach
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diane G Li
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annie Yang
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashley Russo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katherine S Panageas
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Clark JM, Boffa DJ, Meguid RA, Brown LM, Cooke DT. Regionalization of esophagectomy: where are we now? J Thorac Dis 2019; 11:S1633-S1642. [PMID: 31489231 DOI: 10.21037/jtd.2019.07.88] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert A Meguid
- Division of Thoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
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17
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Hoag JR, Resio BJ, Monsalve AF, Chiu AS, Brown LB, Herrin J, Blasberg JD, Kim AW, Boffa DJ. Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery. JAMA Netw Open 2019; 2:e191912. [PMID: 30977848 PMCID: PMC6481444 DOI: 10.1001/jamanetworkopen.2019.1912] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. OBJECTIVE To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. EXPOSURES Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. RESULTS A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). CONCLUSIONS AND RELEVANCE The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.
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Affiliation(s)
- Jessica R. Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin J. Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andres F. Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S. Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence B. Brown
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Jeph Herrin
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anthony W. Kim
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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18
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Boffa D. A new low represents a new high in surgical safety. THE LANCET RESPIRATORY MEDICINE 2018; 6:888-889. [PMID: 30442590 DOI: 10.1016/s2213-2600(18)30465-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/20/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Boffa
- Yale University School of Medicine, New Haven, CT 06520, USA.
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19
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Resio BJ, Chiu AS, Hoag JR, Brown LB, White M, Omar A, Monsalve A, Dhanasopon AP, Blasberg JD, Boffa DJ. Motivators, Barriers, and Facilitators to Traveling to the Safest Hospitals in the United States for Complex Cancer Surgery. JAMA Netw Open 2018; 1:e184595. [PMID: 30646367 PMCID: PMC6324377 DOI: 10.1001/jamanetworkopen.2018.4595] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Directing patients to safer hospitals for complex cancer surgery (regionalization) may prevent thousands of mortalities in the United States. OBJECTIVE To understand the potential for individuals to move to safer hospitals: what would inspire them to travel (motivators), what challenges would they face (barriers), and what would enable them to travel (facilitators). DESIGN, SETTING, AND PARTICIPANTS This nationally representative online survey study asked respondents to consider complex cancer surgery at their local hospital or a hospital specializing in cancer an hour farther away. Completed surveys were weighted across sociodemographics to be nationally representative and outcomes were reported as weighted percentages. In January 2018, a panel of 1817 US adults recruited by address- and telephone-based sampling to be nationally representative were invited to take the survey. Data analysis was conducted from January 24, 2018, to September 19, 2018. MAIN OUTCOMES AND MEASURES Proportion of respondents motivated to travel by specific quality and safety indicators (motivators), magnitude in difference that would be necessary, proportion facing specific barriers, and proportion enabled to move by facilitators. Resistant individuals were identified as people who would not travel except for the largest (top quartile) outcomes differences. RESULTS There were 1016 completed surveys (response rate of 55.9%). The weighted median age was 48 years, 52% were female, median annual income was between $60 000 and $75 000, and 85% lived in a metropolitan area. Nonresponders were more likely than responders to be female, younger, nonwhite, less educated, and lower income (female: 54.4% vs 48.3%; P = .01; younger [aged <45 years]: 56.3% vs 37.1%; P < .001; nonwhite: 41.6% vs 30.0%; P < .001; less than college education: 43.8% vs 32.4%; P < .001; income <$30 000: 22.1% vs 17.1%; P = .01). Superior safety or oncologic outcomes, presented separately, motivated an average of 92% of respondents (95% CI, 90%-94%) to travel. One-third were easily motivated, requiring less than 1% advantage in safety or quality, while 12% were particularly resistant across outcomes. Respondents with lower income (income <$25 000: odds ratio, 2.01; 95% CI, 1.19-3.39) and nonwhite race (odds ratio, 1.60; 95% CI, 1.05-2.42) were more resistant to travel. At least 1 barrier was identified by 74% of respondents (95% CI, 72%-77%), most commonly financial (costs/insurance). However, 94% of respondents (95% CI, 92%-96%) with barriers would travel if provided facilitators, many of which were relatively low cost (transportation, parking, and hotel). CONCLUSIONS AND RELEVANCE It appears that most of the US public could be motivated to travel to safer hospitals for complex cancer surgery, yet most would require some support to move. Further efforts to ensure that benefits from regionalization are equitable across sociodemographic strata are indicated.
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Affiliation(s)
- Benjamin J. Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S. Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R. Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Marney White
- Yale School of Public Health, New Haven, Connecticut
| | - Audry Omar
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Andres Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andrew P. Dhanasopon
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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20
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Chiu AS, Resio B, Hoag JR, Monsalve AF, Blasberg JD, Brown L, Omar A, White MA, Boffa DJ. Why Travel for Complex Cancer Surgery? Americans React to 'Brand-Sharing' Between Specialty Cancer Hospitals and Their Affiliates. Ann Surg Oncol 2018; 26:732-738. [PMID: 30311158 DOI: 10.1245/s10434-018-6868-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Leading cancer hospitals have increasingly shared their 'brand' with smaller hospitals through affiliations. Because each brand evokes a distinct reputation for the care provided, 'brand-sharing' has the potential to impact the public's ability to differentiate the safety and quality within hospital networks. The general public was surveyed to determine the perceived similarities and differences in the safety and quality of complex cancer surgery performed at top cancer hospitals and their smaller affiliate hospitals. METHODS A national, web-based KnowledgePanel (GfK) survey of American adults was conducted. Respondents were asked about their beliefs regarding the quality and safety of complex cancer surgery at a large, top-ranked cancer hospital and a smaller, local hospital, both in the presence and absence of an affiliation between the hospitals. RESULTS A total of 1010 surveys were completed (58.1% response rate). Overall, 85% of respondents felt 'motivated' to travel an hour for complex surgery at a larger hospital specializing in cancer, over a smaller local hospital. However, if the smaller hospital was affiliated with a top-ranked cancer hospital, 31% of the motivated respondents changed their preference to the smaller hospital. When asked to compare leading cancer hospitals and their smaller affiliates, 47% of respondents felt that surgical safety, 66% felt guideline compliance, and 53% felt cure rates would be the same at both hospitals. CONCLUSIONS Approximately half of surveyed Americans did not distinguish the quality and safety of surgical care at top-ranked cancer hospitals from their smaller affiliates, potentially decreasing their motivation to travel to top centers for complex surgical care.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | | | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence Brown
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Audrey Omar
- Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Marney A White
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA. .,Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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